Ultrasound-guided Peripheral Venous Access Research Articles

Smart Glasses to Facilitate Ultrasound Guided Peripheral Intravenous Access in the Simulation Setting for Thai Emergency Medical Service Providers.

The ultrasound-guided peripheral venous access (USGPIV) was reported as difficult for novices to perform. Smart glasses equipped with teleconference systems can display real-time ultrasound images to sonographers and consultants which can increase the success rate of this procedure. The purpose of this study was to assess the effectiveness of employing smart glasses for USGPIV. A randomized, simulation study was conducted in emergency medical service (EMS) providers at Srinagarind Hospital, Thailand, from January to April 2023. We randomized participants into two groups which included participants who wore smart glasses during procedures requiring USGPIV (the smart glasses group) and participants who performed USGPIV with no smart glasses (the non-smart glasses group). After participating in USGPIV cannulation training, the simulations were carried out. The primary outcome was the first-attempt success rate, with secondary outcomes including the procedure time and subjective difficulty. Fifty participants were recruited for the study. The smart glasses group was superior to the non-smart glasses group both in terms of first-attempt success rate with no statistically significant (64% vs 60%; P = 0.460) and also demonstrated a shorter procedure time than the non-smart glasses group (25.5 sec vs 42.3 sec; P = 0.003). The participants reported the subjective difficulty score was higher in the smart glasses group (the visual analog scale, VAS = 8). In simulation scenarios, the smart glasses-assisted USGPIV could shorten the procedure time. However, our study did not find significant differences in the first pass success rate of USGPIV between the two groups.

How I Teach: Ultrasound-guided Peripheral Venous Access.

Ultrasound-guided peripheral intravenous (IV) placement is often required for patients with difficult IV access and is associated with a reduction in central line placement. Despite the importance, there is no standardized technical approach, and there is limited ability to attain mastery through simulation. We describe our step-by-step approach for teaching ultrasound-guided IV placement at the bedside using short-axis dynamic guidance, with emphasis on advancing the needle and catheter device almost entirely into the vessel before threading the catheter. Our teaching approach allows the opportunity for trainees to maximize the learning potential of a single insertion experience, which includes focused preprocedure hands-on practice, instruction with real-time feedback at the bedside, and a post-procedure debrief with reinforcement of concepts.

Use of smart glasses for ultrasound-guided peripheral venous access: a randomized controlled pilot study.

ObjectiveSmart glasses can provide sonographers with real-time ultrasound images. In the present study, we aimed to evaluate the utility of smart-glasses for ultrasound-guided peripheral venous access.MethodsIn this randomized, crossover-design, simulation study, 12 participants were recruited from the emergency department residents at a university hospital. Each participant attempted ultrasound-guided peripheral venous access on a pediatric phantom at intervals of 5 days with (glasses group) or without (non-glasses group) the use of smart glasses. In the glasses group, participants confirmed the ultrasound image through the lens of the smart glasses. In the non-glasses group, participants confirmed the ultrasound image through the display viewer located next to the phantom. Procedure time was regarded as the primary outcome, while secondary outcomes included the number of head movements for the participant, number of skin punctures, number of needle redirections, and subjective difficulty.ResultsNo significant differences in procedural time were observed between the groups (non-glasses group: median time, 15.5 seconds; interquartile range [IQR], 10.3 to 27.3 seconds; glasses group: median time, 19.0 seconds; IQR, 14.3 to 39.3 seconds; P=0.58). The number of head movements was lower in the glasses group than in the non-glasses group (glasses group: median, 0; IQR, 0 to 0; non-glasses group: median, 4; IQR, 3 to 5; P<0.01). No significant differences in the number of skin punctures or needle restrictions were observed between the groups.ConclusionOur results indicate that smart-glasses may aid in ensuring ultrasound-guided peripheral venous access by reducing head movements.

Perceptions of Faculty and Students of Point-of-Care Ultrasound Utilization in Medical Education

Objective: To study the perceptions of Medical College of Georgia residency directors and clerkship directors, and students on the utilization of point-of-care ultrasound (POCUS) in medical education and clinical practice. Methods: An online, anonymous survey was distributed to clerkship and residency directors and undergraduate medical education (UME) students. Participants were asked to indicate their level of experience and agreement for teaching specific POCUS applications. Results: The response rate was 40.13% among UME students (N = 274), 100% among residency directors (N = 17), and 100% among core clerkship directors (N = 9). Majority of residency and clerkship directors agreed to include most of the proposed POCUS applications except for pediatric bladder catheterization (35%) and inferior vena cava to evaluate the presence of hypovolemia (46%). There was no more than 12% disagreement to include any application among both cohorts of responders. Within medical students, the most desired application to learn was ultrasound-guided central line placement (58% strongly agreed; 33% agreed) followed by ultrasound-guided peripheral venous access (88% strongly agreed or agreed), and assessment for presence of pericardial and pleural effusion, abdominal / pelvic fluid collections, and cholelithiasis. Conclusions: This survey documents the desired learning and teaching applications for the POCUS curriculum content. Results will be useful for documentation and as a supplement to the development of a national ultrasound education curriculum.

A new device for ultrasound-guided peripheral venous access.

In patients with difficult peripheral venous access, alternative techniques require expertise and are invasive, expensive, and prone to serious adverse events. This brought us to designing a new venous catheter (JLB® Deltamed, Inc.) for the cannulation of medium and large bore veins; it is echogenic, and available in different lengths (60 / 70 / 80 mm) and Gauges (14 / 16 / 17 / 18). We led a multi-center observational convenience sampling study to evaluate safety and effectiveness of JLB. Data was collected from June 2015 to February 2018. Inclusion criteria were age ⩾ 18, difficulty in obtaining superficial venous access in the veins of the arm, need for rapid infusion, or patient's preference. We enrolled 1000 patients, mean age 66.8 years. In total, 951 (95.1%) had the device placed in internal jugular vein, 28 in basilic or cephalic vein, 15 in femoral vein, 5 in axillary vein (infra-clavicular tract), and 1 in the external jugular vein. The procedure was performed by attending physicians or emergency medicine residents under US guidance. Mean procedure time (from disinfection to securing) was approximately 240 s. Mean attempts number was 1.21. Early complications (<24 h) occurred in four patients, consisting in two soft tissue hematoma, one phlebitis, and one atrial tachyarrhythmia. No major complications (such as pneumothorax) were reported. Mean indwelling time was 168 h (7 days); early occlusion/dislocation occurred in four cases. According to preliminary data, the application of JLB appears to be safe, cost-effective, and rapid to place bedside.

Cost-effectiveness of introducing a nursing-based programme of ultrasound-guided peripheral venous access in a regional teaching hospital.

To analyse the cost-effectiveness of care provided to patients in need of peripheral venous access by comparing the traditional approach with a nurse-based ultrasound-guided programme. Letting nurses insert ultrasound-guided catheters is a promising cost-saving approach, but there are few data available to document the efficiency of this type of programme. A cost-efficiency evaluative research design was used. Data were collected over a 6-year timeframe, before and after the implementation of the nurse-based programme. Results show that the evaluation conducted by nurses ensures the right choice of catheter for each patient based on the patient's needs, which decreases costs. The programme also shortens the waiting period between consultation and insertion of the catheter, which reduces costs related to prolonged hospitalisation. The nurse-based programme puts nurses' skills to good use as part of a new practice and helps enhance the efficiency of care and services provided to patients. In addition to the significant cost savings this programme offers, the evaluation leads to an effective use of resources while ensuring optimal care.

A randomized study of training with large versus small vessel size on successful ultrasound-guided peripheral venous access

Our objective was to investigate whether training on phantoms with smaller or larger vessels would improve success rate in novice medical students learning this skill. Medical students who participated in a voluntary, extracurricular ultrasound training day were asked to participate in the study as part of their procedural training. They were given a standardized education and demonstration of how to use ultrasound to place a peripheral intravenous (IV) catheter. They were then randomized to practice three times on homemade phantom models with either a 5-mm or a 2.5-mm diameter simulated vessel. Afterwards, they were observed attempting to place an ultrasound-guided IV on a 5-mm diameter vessel. Successful cannulation rates was the primary outcome. Fifty-one students from five institutions were included in the analysis. No significant difference in success rate, time to cannulation, number of sticks, or number of redirects was seen between the group who trained on the phantoms with the smaller vessels versus those who trained on the phantoms with the larger vessel. A trend towards significance was seen for success rate and number of redirects, favoring the group trained on the smaller vessels, but this did not reach significance. In our small sample, there was no difference in success rate of novice students trained in ultrasound-guided peripheral IV access using either a smaller or a larger vessel phantom. Future work should focus on elucidating other aspects of training in ultrasound-guided procedures and should attempt a similar study with a larger sample size.

Ultrasound-guided peripheral venous access for therapeutic apheresis procedures reduces need for central venous catheters.

Therapeutic and donor apheresis requires adequate vascular access to achieve inlet flow rates of ∼50-100 mL/min. While central dialysis-type venous catheters can usually provide such access, their use includes several associated risks. Some of these risks can be avoided or diminished if adequate peripheral venous access can be established. Some patients have adequate peripheral veins for apheresis that cannot be readily identified visually or by palpation. We hypothesized that ultrasound-guided peripheral venous access would benefit such patients and would lead to placement of fewer central venous catheters. The technique of ultrasound-guided peripheral access for apheresis has been in use at Houston Methodist Hospital since 2012. We performed a prospective review of patients undergoing inpatient and outpatient apheresis at Houston Methodist Hospital from July 1, 2015 to September 30, 2015, to assess its benefit. During this time, we performed 831 procedures on 186 patients, including 787 therapeutic plasma exchanges, three red blood cell exchanges, 41 peripheral stem cell collections. Ultrasound-guided vascular access was used for 68 procedures (8% of all procedures), including 62 therapeutic plasma exchanges, 4 peripheral stem cell collections, and 2 red blood cell changes. Use of ultrasound-guided peripheral access prevented the placement of central venous catheters in 37 (20%) patients, demonstrating its utility in a busy transfusion service.

Ultrasound-guided peripheral venous access: a meta-analysis and systematic review.

The objective of this study was to determine through a systematic review of the literature and meta-analysis whether success rates, time to cannulation, and number of punctures required for peripheral venous access are improved with ultrasound guidance compared with traditional techniques in patients with difficult peripheral venous access. We conducted a systematic search of MEDLINE, Web of Science, The Cochrane Library, ClinicalTrials.gov, Cumulative Index to Nursing, and Allied Health Literature. Studies were included if they met the following criteria: patients of any age identified as having difficult peripheral venous access; real-time ultrasound guidance was used for peripheral venous cannulation; and inclusion of at least one of these outcomes (success rates, time to successful cannulation and number of punctures required). Seven studies were selected for final analysis. Ultrasound guidance improved success rates when compared with traditional techniques [pooled odds ratio (OR) 3.96; 95% confidence interval (95% CI) 1.75-8.94]. No significant difference between ultrasound-guided techniques and traditional techniques was detected for time to cannulation or number of punctures required. In patients with difficult peripheral venous access, ultrasound guidance increased success rates of peripheral venous placement when compared with traditional techniques. However, ultrasound guidance had no effect on time to successful cannulation or number of punctures required for successful cannulation.

Peripheral venous access in the obese patient.

Sir, Intravenous (IV) cannulation, a common procedure in anaesthetic practice, can at times be difficult and frustrating. We report a 46-year-old male, 109 kg, who was scheduled for repair of incisional hernia (related to previous right nephrolithotomy via a subcostal incision) in whom establishing peripheral IV access proved difficult. The patient had undergone several previous surgeries for genitourinary and kidney-related complaints. No peripheral veins were visible or palpable in the extremities. Venous cut-downs had been done in both lower limbs during previous surgeries. The right cephalic vein was visible in the delto-pectoral groove and was successfully cannulated. After establishing standard monitoring, anaesthesia was induced with fentanyl and thiopentone. Tracheal intubation was facilitated with rocuronium. The patient was positioned in left lateral position for surgery. This resulted in positional slowing of the crystalloid infusion rate. The operation table was tilted ≈20° head-down (to make neck veins prominent), and the right external jugular vein was cannulated. The surgery lasted 3 h and the recovery and post-operative course were uneventful. Predictive factors for difficult venous access include obesity, chronic illness, hypovolaemia, history of IV drug abuse, vasculopathy,[1,2,3] oedema, chemotherapy, diabetes and multiple prior hospitalizations.[4] Obtaining IV access can be tedious and time-consuming procedure in the obese. The veins on the dorsum of the hand and the deep brachial vein may be neither visible nor palpable in the obese patient. However, veins on the volar aspect of the wrist may be used for venous cannulation. The external jugular vein is another option but may be difficult to find in the short, thick neck of the obese patient. Placing the obese patient in Trendelenburg position (to make the vein prominent) may not be tolerated because of respiratory embarrassment. The cephalic vein crosses the surface of the anatomical snuff box, superficial to the radial styloid. This vein is referred to as the ‘houseman's friend’ because of its consistent location at this site and its straight course that allows placement of a large bore IV cannula.[5] It communicates with the basilic vein via the median cubital vein at the elbow. Superiorly, the cephalic vein passes between the deltoid and the pectoralis major muscles before it empties into the axillary vein. The cephalic vein is often visible through the skin in the deltopectoral groove and is a potential site for venous access in the obese [Figure 1]. This vein is worth looking for in an obese patient with a difficult peripheral venous access. Loukas et al.,[6] in a cadaveric study, found that the cephalic vein was found emerging superficially in the lateral portion of the deltopectoral triangle in 80% of specimens. In the remaining 20% cases, the cephalic vein was located deep to the deltopectoral fascia and fat. The length of the cephalic vein within the deltopectoral triangle ranged from 3.5 to 8.2 cm (mean 4.8 ± 0.7 cm). The morphometric analysis revealed a mean cephalic vein diameter of 0.8 ± 0.1 cm (range 0.1–1.2 cm).[6] Ultrasound-guided peripheral venous access is also a valuable aid in patients with a known difficult venous access. Nevertheless, knowledge of the potential sites for IV access can improve the success rate for IV line placement in the obese. Figure 1 The cephalic vein (in the deltopectoral groove) and the external jugular vein cannulated (18 gauge cannula) in an obese patient

Ultrasound-guided peripheral venous access

To systematically review the current literature on the effect of using ultrasound (US) guidance for the placement of peripheral intravenous (PIV) catheters in patients with difficult access. A systematic search was performed for the keywords ultrasonography, catheterization, and peripheral vein. A systematic review was performed on randomized-controlled studies comparing the use of dynamic US guidance with the conventional landmark technique. The primary outcome was the success rate of PIV placement and the secondary outcomes included the number of attempts and time to successful PIV placement. A total of 1778 titles were identified from the search and the review identified 50 potentially relevant studies that were reviewed comprehensively; six articles were included in the final review. The six studies enrolled a total of 316 patients, 153 in the control group and 163 in the US group. Two of the studies reported a significantly higher success rate for US on the basis of initial success or the overall success rate. The two pediatric studies found that time to successful cannulation was shorter and fewer attempts were required to achieve success for patients randomized to US compared with the traditional method. The six studies included were found to vary significantly in the definition of difficult venous access, recording of procedure time, definition of success rate, and other important factors, making a meta-analysis inappropriate. On the basis of this review, routine use of US guidance for PIV placement is not strongly supported by the literature.

Technique of ultrasound-guided peripheral venous access in the emergency room

In emergency situations, patients may need a fast and reliable peripheral venous access, which sometimes may be difficult to obtain, because of poor visualization of the superficial veins due to edema, obesity, hypovolemia or local abnormalities. In such cases, insertion of a central line is potentially time consuming and possibly associated with complications. Furthermore, central lines inserted in emergency are known to be at high risk of infection, so guidelines recommend that they should removed within 24 to 48 hours. In this setting, ultrasound-guided placement of a peripheral venous access might be more rapid, safer and more cost-effective than a central line.

Peripheral venous access with ultrasound guidance

Peripheral venous cannulation is a routine procedure. The method is usually easy, however, occasionally it may prove to be difficult or even impossible to perform. Ultrasound can visualize deep veins that are undetectable by palpation and it makes possible to cannulate these veins under direct visual control. Authors routinely use ultrasound for difficult peripheral venous access. In this report they present 3 cases and discuss the practical aspects of ultrasound-guided peripheral venous access. Venous circulation of the arm is briefly reviewed, and ultrasound guidance techniques are discussed with regards to sterility aspects. Furthermore, authors describe a new technique wich they use efficiently for cannulating patients with poor peripheral venous access.

Ultrasound guidance allows faster peripheral IV cannulation in children under 3 years of age with difficult venous access: a prospective randomized study

Ultrasound-guided peripheral venous access (USG-PIVA) presents many advantages over the reference 'blind' technique in both adults and children in emergency situations. To compare USG-PIVA with the blind technique in children <3 years undergoing general anesthesia. After obtaining the approval of the ethics committee and informed consent from the parents, we included all children <3 years scheduled to undergo general anesthesia [surgery, magnetic resonance imaging (MRI)], who presented difficult venous access. The children were randomized into two groups: the US group (USG-PIVA) and the B group (blind). The primary endpoint was time to cannulation (from tourniquet placement to successful IV cannulation), compared between USG-PIVA group and B group by intention-to-treat analysis. Secondary outcomes were success rate at the first puncture, number of punctures, and diameter of the catheters. Cannulations requiring >15 min were considered as failures. In case of failure in group B, USG-PIVA was attempted for a further 15 min. Twenty children were included in each group. Groups were comparable for sex, age, and BMI. Significant differences were observed in median time to cannulation (63.5 s vs 420.5 s, USG-PIVA vs B respectively, P < 0.001); median number of punctures (1 vs 2.5, USG-PIVA vs B, P = 0.004); and success rate at first cannulation (85% vs 35%, USG-PIVA vs B, P = 0.0012). In contrast, overall success rate did not differ significantly between groups (90% vs 85%, USG-PIVA vs B, P = 0.63). Ultrasound-guided peripheral venous access leads to faster peripheral IV access and should therefore be recommended in children presenting with difficult venous access.

Ultrasound-Guided Peripheral Venous Access vs. the External Jugular Vein as the Initial Approach to the Patient with Difficult Vascular Access

Traditionally, Emergency Physicians (EPs) have used the external jugular (EJ) vein to gain vascular access in patients who have failed nursing attempts at peripheral access. Recently, some EPs have used ultrasound (USIV) to gain peripheral access. This study seeks to determine which initial approach by EPs would lead to greater success. This was a prospective, randomized study of all adult patients who presented to the Emergency Department (ED) between June and December 2007. Inclusion criteria were failed nursing attempts at peripheral access (at least three). EPs were 2(nd)- or 3(rd)-year residents who had previously performed more than five each of EJs and USIVs. Patients were randomized into either an initial EJ or USIV approach. Sixty patients were enrolled, 32 in the ultrasound group, 28 in the EJ group. Fifteen different EPs performed access. Initial Success: USIV 84% (95% confidence interval [CI] 68-93%) vs. EJ 50% (95% CI 33-67%), p = 0.006. Success if EJ visible: USIV 84% vs. EJ 66% (p = 0.18). Overall success, including data from the crossover pathway: a total of 41 lines were successfully placed by ultrasound out of 46 attempts (89%) vs. 18 out of 33 for EJ (55%), p = 0.001. In total, 59/60 patients (98%) had a peripheral i.v. successfully placed. The percentage of functioning lines when the patient left the ED was: USIV 89% (95% CI 72-96%) vs. EJ 93% (95% CI 68-98%), p = 0.88. As an initial approach to all patients with difficult venous access, ultrasound-guided peripheral lines are superior to the EJ approach. However if the EJ was visible, there was no difference in success among the initial approaches. Both techniques, when used together, could achieve peripheral vascular access in 98% of difficult access patients.

270: Ultrasound-Guided Peripheral Venous Access by Emergency Medical Technicians in Patients With Difficult Access

270: Ultrasound-Guided Peripheral Venous Access by Emergency Medical Technicians in Patients With Difficult Access

278: Ultrasound-Guided Peripheral Venous Access by Emergency Medical Technicians

278: Ultrasound-Guided Peripheral Venous Access by Emergency Medical Technicians

Ultrasound Guidance for Peripheral Venous Access

Asheville Surgery Center, Asheville, North Carolina. stonemd@charter.netThank you for your interest in ultrasound-guided peripheral venous access. My intent in reporting this series1was to demonstrate to anesthesiologists that ultrasound-guided peripheral venous access using a simplified Seldinger technique has a good success rate and is not time-consuming. The simplified Seldinger approach facilitates the use of the longer catheters that the deeper veins may require but does not require the gown, large drape, and extra table required by a standard Seldinger technique.I agree that defining difficult venous access is subjective. Costantino et al. 2defined difficult intravenous access as failure with at least three attempts. His study of emergency department patients with difficult intravenous access demonstrated that ultrasound-guided intravenous catheter insertion (when compared with further standard approach) increased success rates, required less time, and increased patient satisfaction. I find, in most cases, when the surface veins are difficult to see and feel, the deeper veins of the antecubital fossa and upper arm remain large and easy to cannulate with ultrasound guidance. Even in patients with a history of intravenous drug abuse, the basilic vein is usually accessible and is not thrombosed. I believe the success I demonstrated was not exaggerated by the use of a more liberal definition of difficult intravenous access.I can further define the cost of ultrasound-guided peripheral venous access using a simplified Seldinger technique. The technique requires the 20-gauge, 10.8-cm arterial catheterization set (FA-0420; Arrow International, Reading, PA) costing $11.24 and the occlusive dressing to cover the ultrasound probe (Tegaderm 10 × 12 cm; 3M, St. Paul, MN) costing $0.71. The cost of the ultrasound gel is negligible. The ultrasound unit was purchased previously for regional anesthesia and therefore did not add to the cost of the procedure. Our standard safety intravenous catheter (ProtectIV Plus-W 20-gauge 1¼-inch; Medex Inc., Carlsbad, CA) costs $1.77. The added cost of the ultrasound-guided technique is therefore $10.38. One must weigh this cost against the cost of continuing a standard approach: additional intravenous catheters, increased time to cannulation, and increased patient discomfort. Different practitioners will likely have different thresholds for changing to an alternative insertion site (leg, external jugular, central vein) or technique (ultrasound) based on the specifics of the patient and the type of surgery.I agree that assistance may be hard to find in a busy ambulatory surgery center. I have been able to perform the procedure alone in many cases. If the needle tip is well visualized in a vein, one can drop the ultrasound probe to advance the integral wire. If the wire advances easily, it is likely in the vein, and the catheter should advance easily. If the wire does not advance easily, the ultrasound should be used again to place the needle tip into the vein.I believe the ultrasound-guided technique has been demonstrated by others to improve success rates in patients with difficult intravenous access. I believe the simplified Seldinger technique I describe facilitates cannulation of the deeper veins at a relatively low cost, in a time-efficient manner and usually by a single practitioner.Asheville Surgery Center, Asheville, North Carolina. stonemd@charter.net

Optimizing Venous Access Using the Web

Optimizing Venous Access Using the Web

Ultrasound-guided Peripheral Venous Access: A Comparison of Two Techniques: Locate, Align, Puncture (LAP) Versus Locate, Align, Mark, Puncture (LAMP)

Ultrasound-guided Peripheral Venous Access: A Comparison of Two Techniques: Locate, Align, Puncture (LAP) Versus Locate, Align, Mark, Puncture (LAMP)